Country Manor Campus

CALL US TODAY: (320) 258-8946

ABOUT
SERVICES
SPECIALTIES
EQUIPMENT
PATIENTS
DOCTORS / PHYSICIANS
CONTACT

DOCTORS / PHYSICIANS

Physician Orders/Referral

Physician Orders/Referral

Name of Patient

Patient D.O.B.

Patient Phone

Diagnosis (include ICD 10 Codes if available)

Therapy Orders (select one or more)

PT Eval & Treat

OT Eval & Treat

ST (SLP) Eval & Treat

Specialty Programs and Services (check any/all that may apply)

Aquatic Therapy

Balance / Fall Prevention Program

Cognitive Testing/Therapy

Dry Needling

Dysphagia Rehab

Home Safety

Language & Communication Rehab

Low Vision Program

Neck / Back Pain Program

Neuro Rehab

Orthopedic Rehab

Pre/Post Operative Rehab

Strengthening Program

Temporomandibular Disorders (TMD)

Vestibular Therapy

Wheelchair Assessment

Precautions / Special Instructions / Additional Recommendations

Additional Document(s) Upload

Physician Name

Date

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A Country Manor Service

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LOCATION
520 First Street NE

Sartell, MN 56377

Country Manor Homepage

CONTACT US
championrehabinfo@countrymanor.org

Call Us: (320) 258-8946

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